Cath Lab Digest

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Index: Ostomy Wound Manage. 2008;54(6):50-65.

  Providing care for patients with challenging wounds and comorbidities requires an open mind. When Ms. T, an elderly woman with schizophrenia and a chronic diabetic foot ulcer that was not responding to treatment, presented at Victory Memorial Hospital Diabetic Foot Clinic (VMH DFC), Brooklyn, NY, care providers needed a plan that allowed consideration of all available care options to achieve the best outcomes.

  The well-known nursing theorist/researcher Sister Callista Roy’s¹ perspective on the human experience can be easily applied in wound care. On the sensitive relationship between man and the environment, Sister Roy writes about an ongoing adaptation, survival, and resilience as part of a journey through life. Similarly, wound care clinicians continually address the issue of maladaptation as a factor in the breakdown of the integumentary system. When the skin – the organ of temperature regulation and the major barrier to microbial invasion – has been compromised, the body is in danger of invasion by organisms that can lead to sepsis and death. In this case study of a patient with a diabetic foot ulcer, the patient’s altered coping mechanisms were rendered less effective by diabetes mellitus² and other comorbidities that required persistence and ingenuity from caregivers.

  Offloading is a recognized option for foot ulcers. One such option – total contact casting (TCC), which provides pressure relief and a moist wound-healing environment and facilitates patient mobility while the wound is healing – is not practiced in many centers, primarily because of the scarcity of Board-certified pedorthists (BCPs) competent, knowledgeable, and experienced regarding application and modification of the casts. Additionally, to be done correctly, clinicians using TCC need approximately 45 minutes for the procedure in addition to the time needed for the initial removal of the cast and dressing, and assessment of the wound. Thus, experience teaches this approach is not widely used.

  The authors’ diabetic foot clinic is part of a larger outpatient department at the facility. Clinicians at this non-profit clinic do not bill patients privately for any service. The care team includes a Board-certified pedorthist (BCP) experienced in TCC; once peripheral circulation and perfusion to the lower extremities are determined to be intact, patients with plantar ulcers (weight-bearing surfaces) are immediately considered for TCC. Patients also are evaluated for any lower extremity weakness, motor imbalances, and unsteady ambulation that might make TCC unsafe, as well as for sufficient cognitive ability to follow instructions regarding the use of assistive devices such as a cane or walker.

  Ms. T presented with an ulcer of >18 months duration with no evidence of cellulitis or gangrene. She was evaluated and met the criteria for TCC; casting was started along with treatment involving a succession of topical wound dressings and applications whenever wound healing showed signs of slowing. The casting stabilized the local wound environment, keeping the patient infection-free for 5 years until the wound closed. Moisture-control foam dressing impregnated with nanocrystalline addressed moisture balance and bacterial control necessary to achieve healing within the closed, protected environment created by TCC until the wound finally responded. Total contact casting (see “Total Contact Casting: The Details”) appeared to be the pivotal treatment that provided a healing environment for this serious wound.